Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per patient day (PPD) for 20 out of the 21 days reviewed. Specifically, during the periods from November 10 to November 16, November 24 to November 30, and December 13 to December 19, 2024, the facility consistently fell short of the required nursing care hours. The daily PPD ranged from 2.81 to 3.19 hours, with most days not reaching the mandated 3.2 hours. This deficiency was confirmed through a review of nursing staffing hours and an interview with the Administrator on December 19, 2024.
Plan Of Correction
P5640 1. Findings of nursing staff care hours cannot be retroactively corrected. 2. Facility will provide a minimum of 3.2 hours nursing care hours per patient day. Staffing team will meet daily Monday-Friday to review staffing needs and create plans to ensure adequate coverage. 3. Scheduling manager will be educated on the requirement of providing a minimum of 3.2 nursing care hours per patient per day. 4. Director of Nursing or Designee will conduct random audits to verify that facility is providing a minimum of 3.2 nursing care hours per patient per day weekly for 4 weeks and then monthly for 2 months thereafter. Audit results will be presented at the QAPI meeting for review and recommendations.